DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Hallux abductovalgus, left foot.
POSTOPERATIVE DIAGNOSIS: Hallux abductovalgus, left foot.
OPERATION PERFORMED: Acquired bunionectomy with opening first metatarsal wedge osteotomy and internal staple fixation.
SURGEON: John Doe, DPM
ANESTHESIA: Monitored anesthesia care with local consisting of 20 mL of 1:1 mixture of 0.5% Marcaine plain and 2% lidocaine plain injected in an ankle block fashion.
PATHOLOGY: None.
HEMOSTASIS: Left pneumatic ankle tourniquet set at 250 mmHg.
ESTIMATED BLOOD LOSS: Less than 3 mL.
MATERIALS: One stainless steel bone staple, also tricortical bone allograft.
INJECTABLES: None.
COMPLICATIONS: None.
DISPOSITION: The patient tolerated the procedure and anesthesia well and was transferred to the recovery room with vital signs stable and vascular status intact to the left lower extremity.
DESCRIPTION OF OPERATION: Under mild IV sedation, the patient was brought back to the operating room and placed on the operating table in a supine position. A well-padded left pneumatic ankle tourniquet was placed about the patient’s left ankle. The above-mentioned cocktail was injected into the left ankle for local anesthesia. The left foot was then scrubbed, prepped and draped in the usual aseptic manner. The foot was then elevated and exsanguinated using an Esmarch bandage. The tourniquet was inflated.
Attention was then directed to the dorsal aspect of the patient’s left foot where an incision, approximately 8 cm long, was made, starting medial and parallel to the extensor hallucis longus tendon distally and covering more laterally, and a lazy S type incision ending approximately over the interspace between the first and second metatarsal spaces. Incision was carried down to superficial and deep structures. Care was taken not to retract all vital neurovascular structures. All bleeders were ligated and cauterized as necessary. Once down to the level of the periosteum, a standard lateral capsulotomy release was performed over the lateral aspect of the first metatarsophalangeal joint. This included fibular sesamoidectomy. The hallux was put through sagittal plane range of motion and excellent correction of the lateral deviation of hallux was noted.
The capsular incision was then made exposing medial aspect and dorsal aspect of the first metatarsal head. All bony prominences dorsally were rongeured down. The sagittal saw was utilized to resect the medial prominence and dorsal prominence of the first metatarsal head. The periosteal incision was then carried down over the periosteum at the base of the first metatarsal and reflected off of the base and dorsal aspect, medial aspect to the base of the first metatarsal. Once that was done, a 0.035 K-wire was driven from dorsal to plantar along the lateral base of the first metatarsal to access the guidewire.
Next, the sagittal saw was utilized to make oblique-type incision to allow for lateral translocation of the first metatarsal and some plantarflexion of the head. Once the K-wire was drilled, the sagittal saw was then passed to make the osteotomy site. The osteotomy was then opened up utilizing a combination of an osteotome. Once the osteotomy was opened up, it was measured to approximately 4 mm opening. Intraoperative fluoroscopy was utilized to demonstrate that the IM angle would be corrected at that length.
Next, tricortical bone allograft was utilized. The bone graft was inserted into the open osteotomy. It was tamped in and then it was fixated with the OsteoMed staple, which was predrilled utilizing 0.035 inch K-wire. Once the OsteoMed staple was placed in there, excellent compression of the osteotomy site was noted. Remaining defects were packed with cancellous bone from the allograft.
The area was then copiously flushed with normal sterile saline. Deep closure was obtained utilizing 3-0 Vicryl and 4-0 Vicryl, reapproximated subcutaneous, and skin was reapproximated utilizing 4-0 Prolene in running subcuticular fashion. The area was then dressed with Steri-Strips, Adaptic, Betadine-soaked 4 x 4s, additional 4 x 4s, Kerlix, Kling, Webril, EBIce cooler, and modified posterior splint. Tourniquet was inflated and prompt capillary response was noted to the left lower extremity. The patient was monitored in recovery with above-mentioned sedation before being discharged home.
